Angiotensin-converting enzyme inhibition or angiotensin receptor blockade in hypertensive diabetics?

Hypertension increases the renal and cardiovascular risks in diabetic patients. The beneficial effects of angiotensin-converting enzyme inhibitors and angiotensin receptor blockers on renal and cardiovascular outcomes are discussed in this paper, with a particular focus on their optimal use in the hypertensive diabetic patient, with or without evidence of renal or cardiovascular disease. Although the mechanism of action of the two drug classes is not entirely similar, there is no evidence of differences in their clinical effects. Importantly, the achieved risk reduction with either drug is not similar across subsets of diabetic patients. Overt nephropathy of type 2 diabetes appears poorly responsive even to maximized renin-angiotensin system inhibition. This urgently calls for new interventions that may decrease renal and cardiovascular risk through other mechanisms than blood pressure lowering alone. Improving the outcome of type 2 diabetics is the major clinical challenge for the beginning of the third millennium.